Basic Information
| Provider Information | |||||||||
| NPI: | 1669409330 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | YUMA GASTROENTEROLOGY PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 27340 | ||||||||
| Address2: | PHOENIX | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850617340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6029439200 | ||||||||
| FaxNumber: | 6022163000 | ||||||||
| Practice Location | |||||||||
| Address1: | 1030 W 24TH ST | ||||||||
| Address2: | SUITE H | ||||||||
| City: | YUMA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853648345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9283444325 | ||||||||
| FaxNumber: | 9283433084 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2006 | ||||||||
| LastUpdateDate: | 01/16/2008 | ||||||||
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| AuthorizedOfficialLastName: | ANIREDDY | ||||||||
| AuthorizedOfficialFirstName: | DIVESH | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 9283433084 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 907298 | 05 | AZ | MEDICAID | 5427531 | 01 | AZ | AETNA | OTHER | 112955 | 01 | AZ | HEALTH PARTNERS | OTHER | 5397003 | 01 | AZ | CIGNA | OTHER |